EmailMe Form - HR Camp Youth Registration Form

Camper Name *

First Last

Date of Birth *

MM / DD / YYYY

Today's Date *

MM / DD / YYYY

Grade entering in the fall:

Camper Address *

Street Address City State / Province / Region Postal / Zip Code

Camper Cell *

### - ### - ####

Church / Youth Group *

PERSONAL COMMITMENT: *

I agree with this statement.

I agree to participate FULLY in the Hollow Rock Youth Program. I also commit to abide by the rules of the camp and to submit to the Camp Youth Staff Leadership.

PARENT / GUARDIAN INFORMATION

Please enter the name of the parent or guardian who should be contacted in the case of an emergency.

Parent / Guardian #1 Name *

First Last

Relationship *

Parent / Guardian #1 Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Parent / Guardian #1 Phone *

### - ### - ####

Parent / Guardian #1 Email *

Parent / Guardian #2 Name

First Last

Relationship

Parent / Guardian #2 Address

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Parent / Guardian #2 Phone

### - ### - ####

Parent / Guardian #2 Email

MEDICAL INFO/RELEASE

PARENT PERMISSION: I hereby grant permission for my child to fully participate in all activities of The Hollow Rock Camp Meeting. While I understand that Hollow Rock Camp Meeting will take all reasonable steps to provide care and safety for my teen. I hereby release and hold harmless from liability Hollow Rock Camp Meeting, its board members, staff members, volunteer members, and/or agents in the event of injury to my teen not resulting from the negligence of any such, volunteers and/or agents while my teen is engaging in any camp activity. In permitting my teen to participate, I agree that such responsibility will remain with me, as parent or guardian of my teen.

EMERGENCY AUTHORIZATION: I hereby give permission to the medical personnel attending to the treatment of my child to order x-rays, routine tests and treatment. In the event I cannot be reached in an emergency, I hereby give permission to the attending physician to hospitalize, secure treatment for, and to order injection and/or anesthesia and/or surgery for my teen named on this form.
We will make every effort to contact the listed Parents/Guardians in the event of an injury.

Full Name of Insurance Company *

Policy Holder Name *

Group Name *

Group # *

Insurance Company Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code

Name of Family Physician *

Physician Phone *

### - ### - ####

Name of Dentist / Orthodontist

Dentist / Orthodontist Phone

### - ### - ####

Date of last tetanus shot *

MM / DD / YYYY

Medications your teen is currently taking *

Please add scheduled times and dosage amounts. All medications will be turned into camp nurse at check-in. Medications must be in their original containers with the camper’s name and name of medication on container.

Emergency Contact #1 (if different from above)

First Last

Relationship

Parent/Guardian Release
I, as the parent/guardian, grant my teen permission to engage in all prescribed camp activities except as noted and I am in agreement with the statements above (Parent Permission & Emergency Authorization). *

Yes

No

I, as the parent/guardian, willingly allow camp staff to take pictures of my teen for possible use on social media updates and other promotions sponsored by Hollow Rock Camp and its affiliates.

Yes, you may take photos of my teen.

No, you may NOT take photos of my teen.

CONFIRMATION SIGNATURE

Clear

By acknowledging and signing above, I am delivering an electronic signature that will have the same effect as an original manual written on parchment signature. The electronic signature will be as binding as an original manual written signature. I acknowledge that all information given above is true.

Date Time

MM / DD / YYYY

Date Time

MM / DD / YYYY

Name

First Last